When assessing a client's vital signs, a nursing student has explained each of her next actions prior to assessing the client's temperature, pulse, and blood pressure.
However, the nurse has not announced her intention to assess the client's respiratory rate prior to measuring it. Which of the following is a plausible rationale for the nurse's decision?
A) Respirations have both autonomic and voluntary control.
B) The nurse likely assessed the client's respiratory rate simultaneous to heart rate.
C) Temperature, pulse, and blood pressure are more volatile than respiratory rate.
D) Tachypnea is an expected finding among hospitalized individuals.
Question 2
An male client 86 years of age with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia.
The nurse has attempted to assess his temperature using an oral thermometer, but the client is unable to follow directions to close his mouth and secure the thermometer sublingually. Additionally, he repeatedly withdraws his head when the nurse attempts to use a tympanic thermometer. How should the nurse proceed with this assessment?
A) Assess the client's temperature by axilla.
B) Assess the client's skin tone and the presence or absence of sweating to determine whether the client is febrile.
C) Use a disposable mercury thermometer to take the client's temperature.
D) Take the client's temperature rectally.
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